nutrients Article Serum n-6 Fatty Acids are Positively Associated with Growth in 6-to-10-Year Old Ugandan Children Regardless of HIV Status—A Cross-Sectional Study Raghav Jain 1 , Amara E. Ezeamama 2, Alla Sikorskii 2, William Yakah 1 , Sarah Zalwango 3, Philippa Musoke 4, Michael J. Boivin 5,6 and Jenifer I. Fenton 1,* 1 Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI 48824, USA; [email protected] (R.J.); [email protected] (W.Y.) 2 Department of Psychiatry, Michigan State University, East Lansing, MI 48824, USA; [email protected] (A.E.E.); [email protected] (A.S.) 3 Directorate of Public Health and Environment, Kampala Capital City Authority, Kampala 00256, Uganda; [email protected] 4 Makerere University-Johns Hopkins University Research Collaboration, Kampala 00256, Uganda; [email protected] 5 Departments of Psychiatry, Neurology & Ophthalmology, Michigan State University, East Lansing, MI 48824, USA; [email protected] 6 Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, USA * Correspondence: [email protected]; Tel.: +1-517-353-3342; Fax: +1-517-353-8963 Received: 8 April 2019; Accepted: 30 May 2019; Published: 4 June 2019 Abstract: Fatty acids (FAs) are crucial in child growth and development. In Uganda, antiretroviral therapy (ART) has drastically reduced perinatal human immunodeficiency virus (HIV) infection of infants, however, the interplay of FAs, ART, and HIV in relation to child growth is not well understood. To investigate this, serum was collected from 240 children between 6–10 years old in Uganda and analyzed for FAs using gas-chromatography mass-spectrometry. HIV status and anthropometric measurements were taken, and relationships with FAs were assessed. No significant differences in growth parameters or serum FAs were found between HIV uninfected children with and without exposure to ART. HIV positive children had significantly lower height-for-age-z-scores (HAZ) than uninfected children (p < 0.001). HIV-positive children had higher arachidonic acid than uninfected children (p = 0.003). Total omega-6 FAs were significantly associated with HAZ regardless of HIV status (p = 0.035). Mean total omega-3 FAs (2.90%) were low in this population compared to other cohorts in Africa. These results provide reference serum FA values for 6–10-year-old children in Uganda and may be used to inform lipid supplementation programs to promote child growth. Future studies should investigate the relationships between child growth trajectories in relation to HIV status and serum FAs. Keywords: fatty acids; Uganda; HIV; arachidonic; omega-3; linoleic; omega-6; docosahexaenoic acid (DHA); growth; stunting 1. Introduction Fatty acids are a major source of energy and are involved in a variety of bodily functions ranging from cellular signaling [1] to the development of bone mass [2]. Linoleic (LA) and α-linolenic (ALA) acids are essential omega-6 (n-6) and omega-3 (n-3) FAs, respectively, and can only be obtained through the diet. LA and ALA are elongated and further desaturated through shared enzymatic pathways to produce long chain polyunsaturated FAs (PUFAs) which are crucial to growth, development, and maintenance of cellular homeostasis [3]. Long chain PUFAs may also be obtained through the diet. Nutrients 2019, 11, 1268; doi:10.3390/nu11061268 www.mdpi.com/journal/nutrients Nutrients 2019, 11, 1268 2 of 15 The effect of FAs on child growth and development differs based on the age of the child and type of FA. Supplementation of n-3 FAs to pregnant mothers results in lower early pre-term births and higher child birthweight [4]. Additionally, n-3 FAs are required for the proper development of the central nervous system in newborn children, particularly the n-3 docosahexaenoic acid (DHA) [5]. Meanwhile, whole blood n-6 FAs are associated with positive linear growth in children between the ages of 2 and 6 years in African populations where child stunting is a public health challenge [6,7]. The majority of research on FAs and child growth focuses on children between 0–59 months of age, particularly in developing nations such as Uganda where early childhood stunting is prevalent (30.6% of children under 5 years old) [8] and has long-term, adverse health and economic implications [9,10]. However, more research is necessary to understand the relationship between FAs and growth of older children aged 6–10 years old in developing African nations. Dietary intake plays an important role in determining the FA status of individuals. In Uganda, the diet consists mainly of foods high in carbohydrates such as cereals, sweet potatoes, and cassava. Despite access to freshwater sources, the consumption of fish, a good source of n-3 FAs, is uncommon [11]. This may lead to inadequate n-3 FA intake, causing deficits in child growth and development. According to the Food and Agriculture Organization (FAO), 89% of households in Uganda are food secure, however, nutritional awareness remains low [12]. For example, fruit and vegetable consumption by adults is low throughout Uganda, and approximately 90% of adults consume less than the recommended 5 servings of fruits and vegetables per day [13]. This may extend to children as well, negatively impacting growth. Fruits and vegetables are sources of EFAs and low consumption can result in EFA deficiency which may cause growth arrest, hinder development of the central nervous system, and compromise the immune system [14,15]. In Uganda, an estimated 1.3 million individuals were still living with HIV as of 2017, though the rate of new HIV infections has been decreasing since 2009 due, in part, to the implementation of antiretroviral therapies [16]. Standard antiretroviral therapy (ART) consists of several antiretroviral drugs to prevent the progression and transmission of HIV disease and is promoted by the World Health Organization in its goal to end AIDS by the year 2030 [17]. Children born with HIV are at increased risk of pre-term birth and lower overall birth size compared to uninfected children. Additionally, perinatally infected children may also have poorer fat absorption in the gastrointestinal tract than uninfected children which can affect the child FA profile [18]. Long term effects of childhood dyslipidemia include increased risk of obesity, diabetes, and hypertension [19]. Hence, ART therapies are administered to pregnant HIV positive mothers to prevent child HIV infection and its related effects. It is estimated that in 2017, ART therapies helped prevent HIV transmission to 16,000 children from their mothers, approximately double the number of children born with HIV. In Uganda, maternal HIV transmission during birth to children who are now adolescents was prevented primarily by the anti-retroviral drug nevirapine, and levels of growth stunting in children exposed but not infected with HIV due to nevirapine is similar to HIV infected infants [20]. Additionally, food insecurity is typically higher in the households of people with HIV or AIDS due increased medical costs, resulting in less resources to purchase food [21]. Therefore, there may exist a relationship between child HIV status and ART exposure, and serum FA composition, influencing growth. This study aimed to identify differences in FAs and growth based on HIV status in children between the ages of 6–10 years old in Kampala, Uganda. It was expected that HIV positive and ART exposed children would have an altered serum FA profile than uninfected, unexposed children which could have adversely affected their growth. These results establish reference serum FA values and may be used to develop future lipid-based interventions to support healthy growth in adolescent Ugandan children regardless of HIV status. Nutrients 2019, 11, 1268 3 of 15 2. Materials and Methods 2.1. Study Context Participants were enrolled from the Kawempe Division of Kampala, Uganda—a region with the highest prevalence of HIV (11%), compared to national prevalence of 7.3% [22]. Participants were enrolled in the context of primary care at Kawaala Health Center (KHC)—a level 3 Health Center that delivers the full range of antenatal care services, including deliveries, out-patient consulting for the general population, and the entire range of HIV/AIDS treatment and preventive services. As a birth cohort, HIV-exposed eligible children included in this study were largely born in the pre-antiretroviral therapy era. At the time of their birth, prevention of mother to child transmission of HIV was largely limited to intra-partum and neonatal single dose nevirapine [23,24] and few HIV-infected women received antiretroviral therapy for their own health. 2.2. Participants Ugandan children between 6 and 10 years old and their adult primary caregivers were enrolled between March 15, 2018 and September 15, 2018 as part of a larger study of determinants of functional survival in HIV-infected/uninfected children. All measurements and sample collections were performed at enrollment. Of the 305 children in the parent study, blood samples for laboratory assessment for fatty acid measures was available in 240 that form the study base for the current analysis. Current adult caregivers were enrolled regardless of their HIV status. By design, approximately equal numbers of children with perinatally acquired HIV infection (PHIV, n = 102), perinatally HIV exposed but uninfected (HEU, n = 101) and HIV unexposed uninfected (HUU, n = 102) community control children were enrolled from the same hospital. Some HEU children were also exposed to ART